Tibolone and climacteric symptoms

Comparison of the Efficacy of Tibolone and Transdermal Estrogen in Treating Menopausal Symptoms in Postmenopausal Women

Objectives

This study aimed to compare the efficacy of tibolone and transdermal estrogen in treating menopausal symptoms in postmenopausal women with an intact uterus.

Methods

Overall, 26 women consumed tibolone orally and 31 women received transdermal estrogen gel mixed with progestogen. The menopause rating scale (MRS) was used to assess their menopausal symptoms at their first outpatient visit and 6 months later.

Results

The transdermal estrogen group showed significant improvements in more items of the MRS questionnaire. There was a favorable change in body weight in the transdermal estrogen group compared with that in the tibolone group. Depressive mood, irritability, physical and mental exhaustion, sexual and bladder problems, and joint and muscular discomfort improved only in the transdermal estrogen group, whereas heart discomfort and vaginal dryness improved only in the tibolone group. Nevertheless, the intergroup differences in each item were insignificant after adjusting for body mass index and hypertension, which differed before treatment.

Conclusions

Both the therapeutic options improved menopausal symptoms within 6 months of use. However, transdermal estrogen appeared to be more effective in preventing weight gain in menopausal women than tibolone.

Different effects of tibolone and low-dose EPT in the management of postmenopausal women with primary headaches

OBJECTIVE

The present randomized prospective study aimed to compare the effect of tibolone (T) with conventional low-dose estrogen-progestogen therapy (EPT) administered in a combined continuous regimen on the course of primary headaches in postmenopausal women requesting hormone therapy (HT) for climacteric complaints.

DESIGN

Forty women presenting for clinical evaluation of headache (migraine without aura and episodic tension-type headache) were enrolled. The observational period lasted 7 months during which women kept a diary of the clinical characteristics of headache attacks and analgesic use. Climacteric symptoms and both anxiety and depression were also measured. After a 1-month run-in period, women received two different HT regimens: 1 mg 17beta-estradiol + 0.5 mg norethisterone acetate (EPT) or 2.5 mg T. Follow-up evaluations were planned after 3 and 6 months of treatment.

RESULTS

Although T did not affect the number of days with migraine without aura, it significantly reduced the number of hours during which pain intensity prohibited daily activities (P < 0.001) and the number of analgesics (P < 0.001) after 3 months. Conventional low-dose EPT administered in a combined continuous regimen was confirmed to have a mild, but negative, effect on the course of migraine without aura by increasing the number of days with head pain (P < 0.001) and the number of analgesics (P < 0.001). Interestingly, both treatments were effective in the management of episodic tension-type headache, significantly reducing the number of days with head pain, severity, and analgesic consumption.

CONCLUSIONS

In postmenopausal headache sufferers, analgesics are more effective in alleviating severe head pain when women are treated with T in comparison with low-dose EPT for climacteric complaints.

The incidence and characteristics of uterine bleeding during postoperative GnRH agonist treatment combined with tibolone add-back therapy in endometriosis patients of reproductive age

OBJECTIVES

This study was undertaken to evaluate the incidence and the factors associated with uterine bleeding while taking GnRH agonist treatment combined with tibolone add-back therapy in endometriosis patients of reproductive age.

STUDY DESIGN

The medical records of 188 endometriosis (stages III-IV) patients of reproductive age receiving postoperative GnRH agonist treatment combined with tibolone add-back therapy for 6 months were reviewed. Clinical features were analyzed and compared between the two groups: Group A, patients without an episode of uterine bleeding (n=137) and Group B, patients that had experienced uterine bleeding (n=51).

RESULTS

Demographic profiles were not different in the two groups. The incidence of uterine bleeding was 27.1% and irregular spotting was the most frequent bleeding pattern. The proportion of patients who received ovarian surgery during pelviscopy was higher in Group B (p<0.05), but other clinical characteristics were not different between two groups.

CONCLUSIONS

The incidence of uterine bleeding was 27.1%. And, the proportion of patients who received ovarian surgery was higher in patients with uterine bleeding.

Assessment of DNA damage in postmenopausal women under osteoporosis therapy

OBJECTIVE

The following study was designed to examine possible DNA damage levels in peripheral blood leukocytes, using the alkaline Comet assay, isolated from postmenopausal women undergoing osteoporosis treatment.

STUDY DESIGN

Thirty-two postmenopausal women were randomized into two groups of 16. A dosage of 2.5 mg/day of tibolone (Livial) and 10mg/day of alendronate sodium (Fosamax) were administered to Group 1 over a 12-month period while Group 2 took 10 mg/day of alendronate alone over the same period. The control group consisted of 16 postmenopausal women who did not receive any treatment. Genotoxicity was assessed by the standard method of alkaline Comet assay.

RESULTS

When the results of the study groups were compared with those of the control group, significant differences in terms of DNA damage levels were found (p<0.05). However, no difference was detected between Groups 1 and 2 (p>0.05).

CONCLUSION

Although, no statistical difference in terms of DNA damage levels between tibolone plus alendronate as opposed to alendronate alone was found, an increase in DNA damage levels was observed in Groups 1 and 2 compared with the control group. Consequently, it can be asserted that the frequency of DNA damage in postmenopausal women with osteoporosis increases under alendronate treatment with or without tibolone.

Hormone replacement therapy (HRT) and endometrial morphology under consideration of the different molecular pathways in endometrial carcinogenesis

The majority of modern hormone replacement therapy (HRT) regimens contain estrogen and progestogens, given either in a cyclical or continuous manner. About 15% of the endometrial biopsies taken from women on sequential HRT show proliferative activity including atypical endometrial hyperplasia in up to 1% of the cases. The majority of biopsies from women under continuous combined HRT show an endometrial atrophy. About 2-3% of these women will present proliferative activity, usually without atypical hyperplasia. Contrary to breast cancer, an increased risk of endometrial cancer has not been reported in the WHI- and HERS-studies. However, endogenous factors, such as obesity, diabetes mellitus, the distribution of estrogen receptors alpha and beta and genetic polymorphisms for receptors and enzymes might alter the endometrial stimulation under different types of HRT. There should be a liberal indication for endometrial biopsies in Hereditary Non-Polyposis Colorectal Cancer (HNPCC). HNPCC-patients under HRT as well as for ultrasonographic evaluation of the endometrium. The risk of atypical hyperplasias or carcinoma under unopposed estrogen-therapy varies from 2 to 10%. So, this kind of HRT should not be used in non-hysterectomised women. As far as the risk of endometrial cancer under any kind of HRT is concerned, the different molecular pathways of endometrial carcinogenesis (type 1 and 2 cancers) should be taken into account. The use of tibolone leaves the endometrium unaffected.

Leuprolide acetate treatment with and without coadministration of tibolone in premenopausal women with menstrual cycle–related irritable bowel syndrome

OBJECTIVE

To evaluate the effectiveness of gonadotropin-releasing hormone agonists (GnRH-a) with or without coadministration of tibolone in women with menstrual cycle-related irritable bowel syndrome (IBS).

DESIGN

Prospective, randomized, placebo-controlled clinical trial.

SETTING

Universities of Catanzaro and Naples.

PATIENT(S)

One hundred twenty young premenopausal women with menstrual cycle-related IBS (Rome II criteria).

INTERVENTION(S)

Administration of leuprolide acetate depot (LAD, 11.25 mg IM/3 months) plus tibolone (group A), LAD plus placebo tablets (group B), and injection of a placebo solution plus placebo tablets (group C).

MAIN OUTCOME MEASURE(S)

Severity of bowel symptoms or signs of IBS and quality of life (QoL), at baseline and after 6 months of treatment.

RESULT(S)

In all groups, the mean scores for each symptom or sign of IBS and for QoL were significantly improved after treatment. A significant difference was observed between group C and groups A and B. No difference between these last groups was detected in symptoms or signs of IBS. The QoL scores were significantly higher in group A than in group B.

CONCLUSION(S)

Gondotropin-releasing hormone agonist administration is effective in women with menstrual cycle-related IBS. The addition of tibolone does not reduce effectiveness compared with agonist alone and increases QoL.

Mammographic breast density changes after 1 year of tibolone use

Hormone replacement therapy (HRT) is widely used with a large variety of regimens and medications. For each of these regimens the goal is the same but there is always a fear about side effects, especially on breast. Mammographic screening is a standard tool for all women receiving hormone replacement therapy. Breast density is very important, because it interferes with the sensitivity of the evaluation and it is also a predictor of malignity.

OBJECTIVE

We planned a study to investigate the effects of tibolone on mammographic breast density.

DESIGN AND METHODS

We studied 70 postmenopausal women who started tibolone therapy (2.5 mg per day) after initial mammography and blood samples taken for biochemical examinations. None of the women used any hormone replacement therapy before. Eleven of them either discontinued the therapy or lost contact. After 1 year, we evaluated 59 women by mammographic status, using Wolfe classification. Mammographies were analyzed by two independent radiologists.

RESULTS

Mammographies of 59 women were compared with the initial ones. While in the low density patterns, there was a slight increase (15%; P < 0.05); in the higher density groups, there was a decrease of 25% as observed by one radiologist, and 16% according to the other (P < 0.05). None of the women had a diffuse, high density pattern. There was no statistically significant inter-observer variation between two radiologists (P < 0.05).

CONCLUSIONS

Wolfe classification allows easy interpretation of mammographic evaluation and the results are reproducible. Tibolone, as a tissue-specific steroid, does not have an estrogenic effect on breast cells. We found that it might limit, even reverse breast density increase, especially in postmenopausal women with high breast density.

Les alternatives au traitement hormonal substitutif de la ménopause : le point épidémiologique

OBJECTIVE

Recent results put into question the risks/benefits ratio of hormone replacement therapy and emphasize the importance of precise knowledge of the effects of other treatments that exist for postmenopausal symptoms or diseases. Our aim is to analyze their effect.

METHODS

A review of randomized trials or epidemiological studies was undertaken.

RESULTS

Bisphophonates, calcitonin, parathormone, strontium ranelate, calcium and vitamin D have specific effects on bone. The efficacy of bisphophonates for prevention and treatment of osteoporosis has been proven and parathormone and strontium ranelate seem promising. These treatments are useful for women at high risk of osteoporosis who do not suffer from menopausal symptoms. Tibolone, SERMs and phytoestrogens exert effects on various tissues. SERMs are very promising, but they do not improve climacteric symptoms and their long term effects are still unknown. Tibolone has beneficial effects on climacteric symptoms and on bone loss, but recent results concerning its effects on the risk of breast cancer call into question its interest. The beneficial effects of phytoestrogens on bone and on vasomotor symptoms need to be confirmed.

CONCLUSION

At this time, none of the existing treatments for postmenopausal symptoms or diseases is ideal. The existence of several options for treatments of symptoms or diseases of the postmenopause is helpful as it affords several choices for physicians and for women who sometimes need to be treated for many years. However several questions remain unanswered concerning the long term effects of these treatments.

Effect of tibolone on breast symptoms resulting from postmenopausal hormone replacement therapy

OBJECTIVE

To evaluate the incidence of breast symptoms in a population treated with various hormone replacement therapy (HRT) regimens and to detect the variations in breast symptomatology after HRT changing to tibolone administration.

METHODS

This prospective placebo-controlled clinical trial was conducted on healthy women on HRT reporting breast symptoms. A questionnaire was given to each woman to detect breast symptomatology. Breast tenderness and mastalgia were evaluated using a visual analogue scale (VAS). According to the choice of the each woman with breast symptoms, the HRT was changed to tibolone (2.5 mg/day per os) or to calcium carbonate (1 tab/day, placebo group). The duration of treatment was of 12 months. After 6 and 12 months breast symptomatology was re-evaluated.

RESULTS

Among the 600 screened women, 64 (10.7%) were suffering from breast symptomatology. After 6 and 12 months of treatment with tibolone or placebo, mean VAS score for breast tenderness and for mastalgia resulted significantly (P<0.05) decreased, without differences between groups, in comparison with basal value. Only one woman had no improvement from the breast symptoms with tibolone administration.

CONCLUSIONS

Shifting from classical HRT to tibolone is followed by a significant reduction of breast symptomatology in postmenopausal women with breast complaints similar to that obtained with treatment withdrawal.

Effect of tibolone administration on heart rate variability and free fatty acid levels in postmenopausal women

OBJECTIVE

To evaluate the effects of tibolone on heart rate variability and plasma free fatty acid levels in postmenopausal women.

DESIGN

Randomized, placebo-controlled trial.

SETTING

University hospital.

PATIENT(S)

Thirty postmenopausal women.

INTERVENTION(S)

Tibolone, 2.5 mg/d, or placebo for 4 months.

MAIN OUTCOME MEASURES

Variability in heart rate and changes in the lipid profile.

RESULT(S)

Anthropometric data were unchanged throughout the study. Compared with placebo, long-term tibolone administration was associated with a decrease in plasma levels of low-density lipoprotein cholesterol, triglyceride, and free fatty acid and homeostasis model assessment index. Furthermore, tibolone administration was associated with an increase in RR interval, total power, and high frequency and decrease in low frequency and the low frequency/high frequency ratio. Finally, the delta decrease in plasma free fatty acid levels correlated with delta low frequency/high frequency ratio independently of age, delta body mass index, delta homeostasis model assessment index, and low-density lipoprotein cholesterol levels.

CONCLUSION(S)

Long-term tibolone administration improves the ratio of cardiac sympathetic tone to parasympathetic tone in postmenopausal women.

The influence of tibolone on quality of life in postmenopausal women

OBJECTIVES

To examine the effect of tibolone, a synthetic steroid with tissue-specific activity, on quality of life in a randomised, double-blind, placebo-controlled study in healthy postmenopausal women.

MATERIAL AND METHODS

A total of 85 women (54.2+/-4.7 years), were randomised to 2.5 mg tibolone (Livial) or to identically appearing placebo pills daily for 12 months. Quality of life was assessed with the Nottingham Health Profile (NHP). Also, information on the occurrence of climacteric complaints and incidences of vaginal bleeding/spotting was gathered.

RESULTS

Compared to baseline values, the tibolone group significantly improved on three out of six NHP domains: overall 46.8-25.3, emotional reactions 6.8-2.9 and sleep 19.0-7.2. In the placebo group a significant difference from baseline was observed on the 'physical mobility' parameter: 6.9-3.0. Significant between-group difference was only reached on the domains 'sleep': tibolone 7.2 versus placebo 15.2 and 'physical mobility': tibolone 3.8 versus placebo 3.0. The occurrence of hot flushes and nightly sweats was significantly lower in the tibolone group compared to placebo after 12 months of treatment. Throughout the study period a total of four women in the placebo, compared to 16 women in the tibolone group, reported vaginal bleeding/spotting.

CONCLUSIONS

A trend favouring tibolone was observed. However, improvements from baseline were only reflected in a significant between-group difference on the domains of sleep and physical mobility. The limited sample size might have caused this ambiguity. Further research in a larger population is recommended to clear this inconsistency.

Effects of different types of hormone replacement therapy on mammographic density

OBJECTIVES

to evaluate the effects of different types of hormone replacement therapy (HRT) on mammographic density in postmenopausal women.

METHODS

In a prospective 1-year study, 121 healthy postmenopausal women were allocated to one of the following five study groups: twenty-six women were treated with continuous transdermal 17beta-estradiol 50 mcg/die plus acetate nomegestrolo 5 mg/die sequentially added for 12 days per month (Group A); 25 women were treated with continuous transdermal 17beta-estradiol 50 mcg/die plus acetate nomegestrolo 2.5 mg/die added every day (Group B); 23 women were treated with continuous transdermal 17beta-estradiol 50 mcg/die (Group C); 24 women were treated with tibolone 2.5 mg/die (Group D); and 23 women not receiving any medication represented the control group (Group E). At the time of recruitment and after 12 months a two-view mammography was performed to evaluate mammographic density according to a quantitative method: type 1 (less than 25% of mammary gland covered by dense tissue), type 2 (from 25 to 75% of total glandular area covered by dense tissue), type 3 (more than 75% of mammary parenchyma covered by dense tissue).

RESULTS

After 12 months of HRT, seven out of 20 patients (35%) in group A, nine of 21 patients (42.85%) in group B, four out of 19 patients (21%) in group C and two of 20 patients (10%) in group D, showed an increase in mammographic density. No variation of density was observed at the second mammographic test in the control group. The mammographic density increase which occurred in groups A, B and C was statistically significant (P<0.05) when compared with group E; no statistically significant difference (P=0.49) was found in mammographic density increase between group D and group E. When the different treatment types were compared each other, a statistically significant difference (P=0.04) was found only between the mammographic density increase occurring in groups B and D.

CONCLUSIONS

HRT may cause an increase of mammographic density. The frequency of the density increase is related to the type of HRT and a replacement therapy including a progestin, especially in continuous combination with estrogen, leads to more evident mammographic changes. Tibolone does not significantly affect mammographic density.

Effect of tibolone and raloxifene on the tail temperature of oestrogen-deficient rats

Oestradiol, clonidine, tibolone and raloxifene were tested for their effects on the tail temperature of oestrogen deficient rats, a potential new model that can be used to test compounds that may be of use in the treatment of hot flushes in humans. Rats underwent ovariectomies or sham operations and their tail temperature and physical activity were measured telemetrically. Oestrogen depletion affected tail temperature in the rats' active, but not their resting phase. During the transition from the resting to the active phase, tail temperature in normal rats dropped by about 6 degrees C, but only by approximately 1 degrees C after ovariectomy. Treatment of the ovariectomised rats with oestrogen, clonidine or tibolone dose-dependently restored the drop in tail temperature. However, raloxifene did not change the tail temperature of ovariectomised rats. Thus, tibolone and raloxifene have different effects on the temperature regulation in the tail. This method of measuring tail temperature free of stress in ovariectomised rats may serve as a useful procedure for selecting compounds that are of potential use in the treatment of hot flushes.

Comparison of the antiatherosclerotic effect of tibolone with that of estradiol and ethinyl estradiol in cholesterol-fed, ovariectomized rabbits

OBJECTIVE

Tibolone is a synthetic steroid with tissue-specific estrogenic, progestogenic, and androgenic properties. The drug relieves climacteric symptoms and prevents osteoporosis but does not stimulate the endometrium. We have previously shown that in laboratory animals tibolone inhibits the atherogenesis induced by a high-cholesterol diet. Therefore, we compared the antiatherosclerotic effect of oral tibolone at different dose levels with that of oral 17beta-estradiol (E2) and ethinyl estradiol (EE).

DESIGN

Atherosclerotic lesion formation (increase in vessel wall cholesterol deposition and fatty streak formation) was measured in ovariectomized rabbits after 20 weeks on an atherogenic diet (fed daily 80 g of a rabbit chow containing 0.4% cholesterol, 3.75% peanut oil, and 3.75% coconut oil) in eight groups: group 1, placebo (n = 35); group 2, control (n = 34) received normal rabbit chow; group 3, E2 group (E2 4 mg, n = 12); group 4, EE group (EE 60 microg, n = 10); and groups 5-8, tibolone (6 mg, n = 12; 2 mg, n = 13; 0.6 mg, n = 25; and 0.15 mg, n = 11, respectively). During the study, blood samples were obtained for the evaluation of plasma triglycerides, cholesterol, lipoproteins, and glutamate pyruvate transaminase. After 20 weeks, the animals were killed, and cholesterol concentration and the formation of fatty streaks in the wall of the aortic arch were evaluated.

RESULTS

In the placebo group, the atherogenic diet induced a mean increase in total plasma cholesterol concentration from 1.1+/-0.1 mmol/L (control group) to 34.1+/-1.8 mmol/L (mean +/- SE). This resulted in an accumulation of cholesterol in the aortic arch from 48+/-4 (control group) to 608+/-44 nmol/mg protein and in the formation of fatty streaks (41.8+/-3.2% of the surface of the aortic arch was covered with fatty streaks). Tibolone had strong dose-dependent antiatherosclerotic effects. It reduced the accumulation of cholesterol in the aortic arch at doses of 6 to 0.15 mg by 99, 97, 87, and 57% and the formation of fatty streaks by 98, 97, 81, and 38%, respectively. E2 had only a marginal antiatherosclerotic effect, whereas EE showed an effect comparable to that of tibolone at doses of 2 to 0.6 mg. With EE, the accumulation of cholesterol in the vessel wall was reduced by 93% and the formation of fatty streaks by 73%. Mean plasma cholesterol concentrations were also reduced by tibolone (64, 70, 61, and 47%) and EE (57%). This reduction was mainly mediated via a reduction in beta-very-low-density lipoprotein cholesterol. Analysis, however, indicated that the observed antiatherosclerotic effects of tibolone and EE, at least partly, are due to a direct effect on the vessel wall and independent of the changes in plasma cholesterol. At equipotent antiatherosclerotic doses, EE showed a stronger uterotropic effect (measured as the increase in uterine weight) than tibolone. EE increased uterine weight from 0.57 g/kg body weight (BW) (control group) to 3.5 g/kg BW; tibolone at doses of 6, 2, 0.6, and 0.15 mg increased uterine weight to 2.5, 2.8, 2.2, and 1.3 g/kg BW, respectively.

CONCLUSION

Tibolone can protect the arterial vessel wall against atherosclerotic lesions induced by a hypercholesterolemic diet. However, it has much less estrogenic effects on the uterus compared with EE at equipotent doses, indicating tissue selectivity for tibolone. The clinical implications of these findings require investigation.

Use of leuprolide acetate plus tibolone in the treatment of severe premenstrual syndrome

OBJECTIVE

To evaluate the effectiveness of GnRH agonist (GnRH-a) plus tibolone in the treatment of severe premenstrual syndrome (PMS).

DESIGN

Prospective, double-blind, placebo-controlled clinical trial.

SETTING

Department of Obstetrics and Gynecology, University of Naples Federico II, Naples, Italy. PATIENT(S); Thirty patients affected by severe PMS, aged 23-29 years (mean age +/- SD, 25.3 +/- 2.9 years).

INTERVENTION(S)

Treatment for two cycles with leuprolide acetate depot (3.75 mg IM for 28 days) in association with tibolone (2.5 mg/d orally) or placebo (1 tablet per day orally).

MAIN OUTCOME MEASURE(S)

The mean severity of each symptom and sign of PMS was evaluated using a visual analog scale during the last 7 days of each treatment cycle in comparison with the last 7 days of the cycle before treatment.

RESULT(S)

Mean scores for each of the adverse psychological/physical and positive psychological symptoms were significantly improved during treatment. No statistically significant difference was detected between patients treated with tibolone and placebo. A significantly lower number of hot flushes per day was observed in groups treated with GnRH-a and tibolone in comparison with GnRH-a and placebo.

CONCLUSION(S)

Tibolone administered in association with GnRH-a does not reduce the therapeutic effect of GnRH-a in women affected by PMS. Tibolone used in association with GnRH-a may provide long-term medical treatment for women with PMS.

Tibolone: what does tissue specific activity mean?

Preclinical studies has found that tibolone can display a weak estrogenic, progestational and androgenic activity. The effect produced depends mainly on the target tissue involved. Clinical data indicate that tibolone produces the hormonal effects needed to treat climacteric symptoms and to prevent long-term effects of the menopause without stimulating breast and endometrial tissues. This clinical profile would be produced by the tissue specific activity of tibolone and its main metabolites. Tibolone's tissue specific activity may be explained by the interplay of several mechanisms, such as the metabolic conversion of tibolone to compounds with different biological activity, the classical interaction with the steroid receptor and the specific local metabolism, within the target tissue. Therefore, the tissue response and thus the clinical effect produced by tibolone in a given tissue seem to depend on the predominating mechanisms and interactions present in that tissue.

Lipid effects, effectiveness and acceptability of tibolone versus transdermic 17 beta-estradiol for hormonal replacement therapy in women with surgical menopause

OBJECTIVE

To compare the effectiveness of tibolone and 17 beta-estradiol on climacteric symptoms, lipid and biochemical parameters in women with surgical menopause.

METHODS

In a prospective randomised clinical trial group comparative study, the effects on the aforementioned parameters, as well as treatment compliance and side effects were studied with oral tibolone 2.5 mg per day and with transdermic 17 beta-estradiol at 50 microg per day for a period of 12 months. Statistical analysis was carried out using the Fisher-test, analysis of the variance (ANOVA) for the two factors and the Bouferoni test.

RESULTS

Lipid metabolism analysis showed lower levels of HDL and triglycerides in the tibolone group. Other biochemical parameters were not affected. Similar reductions in climacteric symptoms were found in both the groups, but the tibolone group revealed a greater improvement in psychological problems and in sexual behaviour. No differences were observed with respect to compliance and side effects.

CONCLUSIONS

Tibolone is as effective or more than 17 beta-estradiol in reducing climacteric symptoms, and shows greater triglyceride and total cholesterol improvements. Tibolone is a good alternative to estrogens in women with surgical menopause.

Long-term administration of tibolone plus gonadotropin-releasing hormone agonist for the treatment of uterine leiomyomas: effectiveness and effects on vasomotor symptoms, bone mass, and lipid profiles

OBJECTIVE

To evaluate the effects of long-term administration of GnRH agonist (GnRH-a) plus tibolone for uterine leiomyomatosis.

DESIGN

Prospective open clinical trial.

SETTING

Department of Gynecology, Obstetrics and Pathophysiology of Human Reproduction, University of Naples "Federico II", Naples, Italy.

PATIENT(S)

Twenty-five subjects with symptomatic uterine leiomyomas.

INTERVENTION(S)

Treatment for 2 years with leuprolide acetate (3.75 mg IM every 28 days) and tibolone (2.5 mg/d per os).

MAIN OUTCOME MEASURE(S)

Uterine and uterine leiomyoma sizes, endometrial thickness, lumbar spine bone mineral density (BMD), bone metabolism, lipid profile, myoma-related symptoms at baseline and every 6 months. Hot flashes and vaginal bleeding episodes recorded in a daily symptom diary.

RESULT(S)

After 6 months of treatment, a significant reduction was observed in uterine and leiomyoma volumes and myoma-related symptoms compared with baseline values. No significant change was observed in bone turnover, lumbar BMD, or serum total cholesterol, low-density lipoprotein cholesterol, or triglyceride levels. High-density lipoprotein cholesterol values were significantly lower than baseline values after 6 months of treatment but not after 18 months of therapy. A low mean number of hot flashes per day was observed.

CONCLUSION(S)

Long-term administration of GnRH-a plus tibolone reduces hot flashes and prevents bone loss without changing the lipid profile.

Estrogen replacement therapy in women with a history of breast cancer

Estrogens are known as potent mammary mitogen substances and are the major stimulus for the growth of hormone-dependent tumors and clearly implicated in the pathogenesis of breast cancer. Therefore it is a general belief that hormone replacement therapy (HRT) after breast cancer will increase the risk of developing recurrences, though there are no clear data available to support this suggestion. No prospective study with a large number of patients and a long treatment period was performed concerning this issue. On the other hand it may not be justifiable to withhold hormone replacement therapy from low-risk patients after menopause, knowing the benefits of this therapy concerning osteoporosis and cardiovascular advantages. Nevertheless, until appropriate clinical trials help to resolve this problem, non hormonal alternatives constitute the standard of care. One possible approach is to treat menopausal women who have had breast cancer symptomatically and avoid ERT unless absolutely necessary. The risk of cardiovascular diseases can be reduced with lifestyle. Tamoxifen has a beneficial effect on serum lipids and the intake for 5 years leads to a 50% reduction in the incidence of fatal myocardial infarction and a decrease in morbidity associated with ischaemic heart disease. Low doses of progestogen is effective for menopausal hot flushes. Tibolone reduces vasomotoric symptoms such as hot flushes and offers benefit on osteoporosis and has shown a significant reduction in high-density lipoprotein cholesterol. Whether replacing of estrogens is safe for patients after breast cancer remains uncertain. There is a need for a large controlled clinical trial to evaluate the safety and advantages of long time estrogen replacement in women treated for breast cancer.

Psychological effects of hormone replacement therapy: a comparison of tibolone and a sequential estrogen therapy

Hormone replacement therapy (HRT) is effective in alleviating vasomotor symptoms but the effect on psychological symptoms is less clear. This study aimed to compare the psychological effects of two regimens of HRT in perimenopausal women in a randomized, initially double-blind, controlled trial. Thirty-eight women reporting climacteric symptoms were randomly allocated into either oral conjugated equine estrogen 0.625 mg daily plus progestogen (norgestrel) 150 micrograms for the last 12 days of each 28 day cycle, or tibolone 2.5 mg/day for 28 days. They were assessed using standardized psychological assessments. There were no significant differences in changes from baseline between the two types of therapy. For both groups combined there were significant improvements compared with baseline in vasomotor symptoms in the first month, plus anxiety, sleep, memory and somatic dysfunction by the second and third months, but not in scores of depression. Log linear analysis of weekly scores showed that depression scores were significantly related to improvement in vasomotor scores independent of type of therapy and time on HRT. Memory problems were related to vasomotor symptoms independent of depression. No difference between the two types of therapy was found, nor any direct effect of HRT on anxiety or depression. The results support the domino theory, suggesting that psychological improvement follows alleviation of vasomotor symptoms.

Tibolone: a review

Tibolone appears to be at least as efficacious as other forms of hormonal replacement therapy (HRT) on climacteric symptoms. It does not cause withdrawal bleeding when used in women with at least 1 year of amenorrhea. It is, therefore, not indicated in perimenopause because it may cause irregular bleeding. The androgenic action of tibolone may have a two-fold benefit: on the one hand, it may help depression and libido more than other forms of HRT, while, on the other hand, it may improve some lipid parameters such as Lp(a), and triglycerides. However, this androgenic action, may also be responsible for the reduction of HDL cholesterol, that may thus reduce the beneficial effect of tibolone on lipids. It is estimated that only 30% of cardiovascular risk protection of HRT is due to improvement of classical lipids parameters while a great role is played by the direct effect of estrogen on vessels. Tibolone, as well as estrogen, has been shown to induce peripheral vasodilatation and also has a direct effect on vascular reactivity thus increasing peripheral blood flow with no changes in blood pressure or cardiac output. Tibolone seems to exert a similar effect as other forms of HRT on markers of bone metabolism and bone mass, but no data is yet available on fracture prevention.

A double-blind, randomised trial comparing the effects of tibolone and continuous combined hormone replacement therapy in postmenopausal women with menopausal symptoms

OBJECTIVE

To compare the effects of two postmenopausal regimens on menopausal symptoms, bleeding episodes, side effects and acceptability.

DESIGN

Double-blind, randomised controlled trial.

SETTING

Twenty-nine sites in Denmark, nine in Norway and six in Sweden.

PARTICIPANTS

Four hundred and thirty-seven postmenopausal women with menopausal complaints. None of these women had had a hysterectomy.

INTERVENTIONS

Daily treatment with tibolone 2.5 mg (n = 218) or 17beta-oestradiol 2 mg plus norethisterone acetate 1 mg (E2/NETA) (n = 219).

MAIN OUTCOME MEASURES

Hot flushes, sweating episodes, vaginal dryness, assessment of sexual life and bleeding patterns; at baseline and after 4, 12, 24 and 48 weeks.

RESULTS

Treatment with either preparation significantly reduced mean scores for hot flushes, sweating episodes and vaginal dryness. The overall discontinuation rate was 28% (tibolone 25%, E2/NETA 31%; P = 0.14), mostly during the first six months. There was a markedly lower cumulative incidence of bleeding or spotting episodes with tibolone compared with E2/NETA (P < 0.0001), mainly during the first six treatment cycles.

CONCLUSIONS

Both tibolone and E2/NETA effectively alleviate menopausal symptoms. However, tibolone caused significantly fewer bleeding or spotting episodes, which were reflected by lower overall rates of bleeding, as well as lower drop-out rates due to bleeding.

A clinical trial of the effects of tibolone administered with gonadotropin-releasing hormone analogues for the treatment of uterine leiomyomata

OBJECTIVE

To evaluate the effects of tibolone therapy in association with GnRH-a on uterine leiomyomata, on climacteric-like symptoms, on bone metabolism, and on the lipid profile.

DESIGN

A prospective, randomized, double-blind, placebo-controlled, clinical trial.

SETTING

Department of Gynecology and Obstetrics, University of Naples "Federico II," Naples, Italy.

PATIENT(S)

Fifty women with symptomatic uterine leiomyomata.

INTERVENTION(S)

Six months of treatment with leuprolide acetate (3.75 mg every 28 days IM) combined with daily placebo tablets (group A) or with 2.5-mg of tibolone per os (group B).

MAIN OUTCOME MEASURE(S)

Uterine and uterine leiomyomata sizes, lumbar spine bone mineral density, biochemical markers of bone metabolism, lipid profile, and myoma-related symptoms were measured at baseline and after 6 months of treatment. Daily symptom diary in which hot flushes and vaginal bleeding episodes were recorded.

RESULT(S)

No differences between the 2 groups in uterine and uterine leiomyomata size and myoma-related symptoms were detected. After 6 months of treatment, there were statistically significant changes from baseline in bone mineral density and in biochemical markers of bone metabolism in group A but not in group B. Vasomotor symptoms were significantly lower in group B than in group A. There was a statistically significant increase (P<.01) in serum total cholesterol, high-density lipoprotein cholesterol, and triglycerides in group A after 6 months of treatment in comparison with baseline values. The difference in serum total cholesterol and triglyceride levels after 6 months of treatment in group B was not statistically significant in comparison with baseline values, but was statistically significant in comparison with group A values (P<.01). In group B, levels of high-density lipoprotein cholesterol were significantly lower after 6 months of therapy in comparison with baseline values and in comparison with group A values (P<.01). There were no statistically significant changes at baseline and after 6 months of treatment in the level of low-density lipoprotein cholesterol in either group.

CONCLUSION(S)

Administration of tibolone in association with GnRH-a reduces vasomotor symptoms and prevents bone loss, without compromising the therapeutic efficacy of GnRH-a alone.

Differential impact of conventional oral or transdermal hormone replacement therapy or tibolone on body composition in postmenopausal women

OBJECTIVE

To compare the effects on body composition and body weight of tibolone vs two different sequential oral or transdermal oestrogen-progestogen hormone replacement therapies versus no therapy.

PATIENTS AND METHODS

One hundred postmenopausal women were assigned to a control group (n = 26), or randomized to 1) tibolone (TIB) 2.5 mg/day (n = 28), 2) oral oestradiol 2 mg/day (PO) plus sequential dydrogesterone 10 mg/day for 14 of 28 days per cycle (n = 26), or 3) transdermal oestradiol patch (TTS) releasing 50 micrograms/day plus oral sequential dydrogesterone 10 mg/day for 14 of 28 days per cycle (n = 20). Body composition was measured at the base-line and every 6 months for 2 years by DXA (Hologic QDR 1000 W).

RESULTS

Total body fat mass increased (P < 0.05) in controls (+3.6 +/- 1.5%) and in TTS treated (+4.7 +/- 2.2%), but not in PO (-1.2 +/- 2.4%) and TIB (-1.6 +/- 2.2%) treated subjects. This increase in total fat mass in controls and TTS treated women was mostly due to an increase in fat mass of the trunk (P < 0.05), but not legs. As a result, a redistribution of body fat to the trunk occurred in controls, TTS and TIB, but not in PO treated women (P < 0.05). Total lean body mass decreased (P < 0.02) in controls (-1.7 +/- 0.7%) and PO (-1.4 +/- 0.6%) but not in TTS (+0.3 +/- 0.8%) and TIB (+0.4 +/- 0.5%) treated subjects.

CONCLUSIONS

The menopause is associated with an increase in total body fat and a decline in lean body mass. Oral oestradiol/dydrogesterone and tibolone prevent total body fat changes, whereas transdermal oestradiol/oral dydrogesterone and tibolone prevent the lean mass changes. Furthermore, oral oestradiol/dydrogesterone prevents the shift to a central, android fat distribution.

The Blatt-Kupperman menopausal index: a critique

The Blatt-Kupperman menopausal index has been used widely in studies of climacteric symptoms, but it now needs to be reassessed. The original index was derived from clinical experience in New York in the 1950s. The index was a combination of self report and physician ratings; it omitted measures of vaginal dryness and loss of libido; no demographic data of the sample were given; weighting was used without statistical justification; terms were ill defined; categories included overlapping scores, and most importantly scores were summed without being based on independent factors. Modern psychometrics has led to the publication of reliable and valid scales. These should be used in climacteric research in preference to the Blatt-Kupperman index.

Comparison of transvaginal ultrasonography and endometrial biopsy in endometrial surveillance in postmenopausal HRT users

OBJECTIVES

To compare transvaginal ultrasonography with histological findings in endometrial evaluation of postmenopausal women using hormone replacement therapy and to evaluate endometrial safety of three hormone replacement therapy regimens.

METHODS

In a randomized, comparative study in postmenopausal women, endometrial safety was evaluated using (1) no hormone replacement therapy, (2) oral micronized 17 beta-estradiol/oral sequential dydrogesterone, (3) transdermal 17 beta-estradiol/oral sequential dydrogesterone, or (4) oral tibolone. 85 Non-hysterectomised subjects underwent transvaginal ultrasonography immediately before Pipelle biopsy at baseline and subsequently after 12 and 24 months. Endometrial thickness and uterine dimensions were determined by transvaginal ultrasonography, and endometrial thickness (double-layer) was compared with biopsy results.

RESULTS

Endometrial evaluation was conveniently performed by transvaginal ultrasonography, and endometrial thickness correlated well with biopsy findings. If endometrial thickness was < 5 mm, the endometrial biopsy sample was either inactive/atrophic or insufficient for histopathological diagnosis. Hyperplastic or malignant changes were not reported. After 24 months, endometrial thickness was increased both in the oral (P < 0.001) and transdermal (P < 0.001) 17 beta-estradiol/dydrogesterone groups, whereas with tibolone the change in endometrial thickness was not different from controls.

CONCLUSION

transvaginal ultrasonography of the endometrium reliably predicts the histological picture in hormone replacement therapy users. Using 5 mm endometrial thickness as cut-off point, more than 75% of biopsies could be avoided. All three hormone replacement therapies were safe with respect to the endometrium. With sequential 17 beta-estradiol/dydrogesterone the expected progestogen-induced secretory pattern was observed, whereas endometrial histology under tibolone closely mimicked the natural atrophic postmenopausal state.

Nonestrogen management of menopausal symptoms

Women who cannot or choose not to take estrogens do have alternatives; however, the options are few and unproven in longterm clinical trials with respect to safety and efficacy. Many available alternative treatments may alleviate the symptoms of the menopause, but do not convey long-term protection against osteoporosis and cardiovascular disease. This article reviews treatment alternatives to estrogen replacement therapy for symptomatic relief.

Effect on sexual life--a comparison between tibolone and a continuous estradiol-norethisterone acetate regimen

OBJECTIVES

to compare the effects of tibolone 2.5 mg (Livial) with those of 17 beta-estradiol 2 mg plus norethisterone acetate 1 mg (Kliogest) on sexual life.

METHODS

in a 48 week, double blind, multicenter study, 437 postmenopausal women were randomised to treatment with either tibolone or 17 beta-estradiol 2 mg plus norethisterone acetate. Treatment groups were compared with respect to different aspects of sexual life with a questionnaire covering sexual experience and responsiveness during the last 30 days.

RESULTS

a total of 315 subjects completed 48 weeks treatment. In the E2/NETA group an improvement after 48 weeks compared to baseline was observed in five out of seven items assessing sexual life. In the tibolone group an improvement regarding all seven items assessing sexual life was seen. When tibolone was compared to E2/NETA significantly higher scores were found for the items assessing 'frequency', 'satisfaction' and 'enjoyment'.

CONCLUSIONS

this study indicate that tibolone and E2/NETA -which both have an androgenic profile-affect several aspects of sexual life positively. The difference with respect to satisfaction with sexual enjoyment and frequency could be of clinical importance.

Tibolone versus conjugated estrogens and sequential progestogen in the treatment of climacteric complaints

OBJECTIVE

Tibolone has been shown to alleviate climacteric symptoms. This study was designed to compare the effect of tibolone (Livial, 2.5 mg daily) on different climacteric complaints and its impact on the endometrium, determined by vaginal ultrasound, with that of conjugated estrogens (Premarin, 0.625 mg daily) continuously for 6 months in combination with the progestogen medrogestone (Colpron, 2 x 5 mg daily for 12 days each month).

METHODS

One hundred and twenty-nine postmenopausal women were recruited and the severity of climacteric symptoms as well as endometrial thickness were recorded at the pre-trial examination and after 1, 3, and 6 months.

RESULTS

With the exception of vertigo, mood depression, mood disorder, loss of libido, and dryness of skin, where tibolone was found to be more effective than conjugated estrogens/medrogestone, climacteric symptoms improved significantly in both groups over the 6-month study period. Endometrial thickness did not increase significantly in the tibolone group, whereas in the conjugated estrogens/medrogestone group there was a highly significant increase after 1 month and still a trend towards significance after 6 months. Recurrence of vaginal bleeding occurred significantly less frequently in the tibolone group than in the comparison group.

CONCLUSION

Tibolone seems to offer a complete treatment of the climacteric complaints whilst avoiding some of the problems associated with classical hormone replacement therapy.